When Solving Dyspareunia Is Not Enough to Restore Sexual Function in Women With Deep Infiltrating Endometriosis Treated With Dienogest

Measurement properties of sexual function assessment questionnaires in women with endometriosis: A systematic review following COSMIN guidelines

INTRODUCTION

Sexual function of patients with endometriosis should be assessed by patient-reported outcome measures (PROMs) that present high reliability and validity. The objective was to study the PROMs used to assess sexual function for patients with endometriosis to improve their selection for research and clinical practice.

MATERIAL AND METHODS

We performed a systematic literature review from January 2000 to September 2023. All studies including women with confirmed endometriosis and assessing sexual quality of life or sexual function or sexual distress were retrieved. Different properties of PROMs used for sexual dysfunction were assessed according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) recommendations. Properties evaluated were: structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness. This literature review was registered on Prospero as 2018 CRD42018102278.

RESULTS

Seventy-four articles with evaluation of sexual function were included. Of the 25 PROMs assessing sexual function, the Female Sexual Function Index (FSFI) was the most frequently used (34/74 [45.9%] items), followed by the Female Sexual Distress Scale (9/74 [12.2%] items) and the Sexual Activity Questionnaire (SAQ) (8/74 [10.8%] items). The most commonly used measurement properties were "hypothesis testing" and "responsiveness". The PROMs with a high level of evidence for these two measurement properties were the FSFI, the SAQ, the Short Sexual Functioning Scale, the Sexual Satisfaction Scale for Women, Sexual Quality of Life-Female, the Brief Profile of Female Sexual Function, and the Sexual Health Outcomes in Women Questionnaire. The FSFI questionnaire appeared to be more relevant for evaluating medical treatment, and the SAQ for evaluating surgical treatment. Only one instrument was specific to endometriosis (the Subjective Impact of Dyspareunia Inventory [SIDI]).

CONCLUSIONS

In this systematic literature review of sexual function assessment questionnaires in endometriosis, the FSFI and the SAQ questionnaires emerged as having the best measurement properties according to the COSMIN criteria. The FSFI questionnaire appears to be suited for evaluating medical treatment, and the SAQ for surgical treatment. The SIDI is the only specific questionnaire, but its responsiveness remains to be defined.

Dienogest in endometriosis treatment: A narrative literature review

Endometriosis is characterized by the implantation of endometrial cells outside the uterus. This hormone-dependent disease is highly prevalent among women of reproductive age. Clinical symptoms of endometriosis include dysmenorrhea, pelvic pain, and infertility, which can negatively impact the overall quality of life of those affected. The medical treatment of endometriosis serves as an important therapeutic option, aimed at alleviating pain associated with the condition and suppressing the growth of endometriotic lesions. As such, it is employed as an adjuvant therapy following surgery or an empirical treatment after the clinical diagnosis of endometriosis. Dienogest, a fourth-generation progestin, has received approval for the treatment of endometriosis in many countries. A growing body of evidence has demonstrated its efficacy in managing endometriosis-associated pain, preventing symptoms, and reducing lesion recurrence. In this review, we examine the clinical efficacy, safety, and tolerability of dienogest in treating endometriosis. We also provide updated findings, drawing from clinical studies that focus on the long-term use of this medication in patients with endometriosis.

Sexual function according to infiltration of endometriosis of the rectovaginal septum: a cross-sectional study

OBJECTIVE

The aim of this study was to associate the degree of infiltration of rectovaginal septum endometriosis with dyspareunia and sexual function.

METHODS

A cross-sectional study was carried out with 127 women followed up at a tertiary hospital from March 2021 to March 2022. The women's sociodemographic and clinical conditions and dyspareunia were evaluated. The sexual function was evaluated by the Female Sexual Function Index.

RESULTS

A total of 53 women with type I, 37 with type II, and 37 with type III rectovaginal septum endometriosis were evaluated. The women had a mean age of 38.76±6.63 years and a mean body mass index of 27.62±5.11 kg/m2. The mean time of diagnosis of endometriosis was 6.94±4.98 years. On average, the study participants engaged in sexual activity/intercourse 1.88±1.25 times per week. There was no difference between the dyspareunia score (p=0.822) and sexual function (p=0.174) according to the types of rectovaginal septum endometriosis. Overall, 93.7% of the women with endometriosis had sexual dysfunction. There was no correlation between the degree of rectovaginal septum endometriosis infiltration with dyspareunia (r=0.05; p=0.55) or sexual function (r=0.07; p=0.39).

CONCLUSION

Women with endometriosis have impaired sexual function, regardless of the degree of endometriosis infiltration.

Segmental Rectum Resection for Deep Endometriosis and Excision Similarly Improve Sexual Function and Pain

Segmental rectum resections for indications other than endometriosis were reported to result in up to 40% sexual dysfunctions. We, therefore, evaluated sexual function after low bowel resection (n = 33) for deep endometriosis in comparison with conservative excision (n = 23). Sexual function was evaluated with the FSFI-19 (Female Sexuality Functioning Index) and EHP 30 (Endometriosis Health Profile). The pain was evaluated with visual analogue scales. Linear excision and bowel resections improved FSFI, EHP 30, and postoperative pain comparably. By univariate analysis, a decreased sexual function was strongly associated with pain both before (p < 0.0001) and after surgery (p = 0.0012), age (p = 0.05), and duration of surgery (p = 0.023). By multivariate analysis (proc logistic), the FSFI after surgery was predicted only by FSFI before or EHP after surgery. No differences were found between low bowel segmental resection and a more conservative excision. In conclusion, improving pain after surgery can explain the improvement in sexual function. A deleterious effect of a bowel resection on sexual function was not observed for endometriosis. Sexual function in women with endometriosis can be evaluated using a simplified questionnaire such as FSFI-6.

The co-effect of sensate focus technique and sexual position changing on sexual function of women who use medical treatment for endometriosis

Endometriosis is one of the most common chronic diseases of women. This study aimed to investigate the effect of sensate focus technique and sexual position changing on sexual function of women who used medical treatment for endometriosis. This clinical trial study was performed on 80 women who used medical treatment for endometriosis. Women were randomly assigned to two groups: in the intervention group, 2 h of verbal educational session were held and at the end of the session, an instruction booklet about sensate focus technique was given to them, the control group received routine treatment. The sexual function and the dyspareunia of the participants were evaluated after 4 and 8 weeks. Eight weeks after the intervention, the mean total score of sexual function in the intervention group was significantly improved compared to before the intervention (p < 0.001). The mean score of sexual pain in the follow-up periods in the intervention group was significantly different compared to before the intervention and control groups (p < 0.001). The sensate focus technique and sexual position change simultaneously improve sexual function in women with endometriosis who used medication.Trial registration: Approval number from Iranian Registry of Clinical Trials: IRCT2200617047812N1 (Registration date: 2020-11-05).Impact StatementWhat is already known on this subject? The role of endometriosis in the genesis of sexual dysfunction in women has been mentioned in several articles. Researches have shown that some sexual positions put less pressure on parts of the pelvis that contain endometrial tissue. The sensate focus technique can improve sexual dysfunction, including hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD), orgasm, dyspareunia, and vaginismus.What do the results of this study add? Have a positive effect on sexual function and dyspareunia in women with endometriosis undergoing medical treatment and improve their sexual function.What are the implications of these findings for clinical practice and/or further research? Medical staff recommended becoming familiar with these techniques to teach sensate focus and sexual position changing to women with endometriosis to improve their sexual function.

Treatment of endometriosis with dienogest in combination with traditional Chinese medicine: A systematic review and meta-analysis

BACKGROUND

Endometriosis is now considered to be a systemic disease rather than a disease that primarily affects the pelvis. Dienogest (DNG) has unique advantages in the treatment of endometriosis, but it also has side effects. Alternatively, Traditional Chinese Medicine (TCM) has been used for over 2000 years in the treatment and prevention of disease and growing numbers of Chinese scholars are experimenting with the combined use of Dienogest and TCM for endometriosis treatment.

OBJECTIVES

This review evaluated the efficacy and safety of TCM in combination with Dienogest in the treatment of endometriosis through meta-analysis.

METHODS

MEDLINE, Embase, the Cochrane Library, PubMed, Web of Science, China National Knowledge Infrastructure, Journal Integration Platform, and Wanfang were used in literature searches, with a deadline of May 31, 2022. Literature quality was assessed using the Cochrane Collaboration "risk of bias" (ROB2) tool, and the "meta" package of R software v.4.1 was used for meta-analysis. Dichotomous variables and continuous variables were assessed using the relative risk (RR) and 95% confidence intervals (95% CI); standard mean differences (MD) and 95% CI, respectively.

RESULTS

Twelve human randomized controlled trials (RCTs) and one retrospective study, all 13 written in the Chinese language, were included in the meta-analysis (720 experiments and 719 controls). The result indicated that TCM plus Dienogest was superior to Dienogest/TCM alone in increasing the cure rates (RR = 1.3780; 95% CI, 1.1058, 1.7172; P = 0.0043), remarkable effect rate (RR = 1.3389; 95% CI, 1.1829, 1.5154; P < 0.0001), invalid rate (RR = 0.2299; 95% CI, 0.1591, 0.3322; P < 0.0001), and rate of adverse effects (RR = 0.6177; 95% CI, 0.4288, 0.8899; P = 0.0097). The same conclusion was drawn from the subgroup analysis.

CONCLUSION

Results suggest that TCM combined with Dienogest is superior to Dienogest or TCM alone and can be used as a complementary treatment for endometriosis. TCMs have potential to improve clinical efficacy and reduce the side effects of Dienogest. This study was financially supported by Annual Science and Technology Steering Plan Project of Zhuzhou. PROSPERO has registered our meta-analysis as CRD42022339518 (https://www.crd.york.ac.uk/prospero/record_email.php).

Combination of laparoscopic side-to-end colorectal anastomosis and vaginal nose (natural orifice specimen extraction) surgery for colorectal endometriosis: Technique and outcomes

Objective:

To investigate the effectiveness of combining side-to-end anastomosis and vaginal NOSE (Natural orifice specimen extraction) surgery in colorectal endometriosis.

Material and methods:

We included 11 patients treated with laparoscopic side-to-end colorectal anastomosis and vaginal NOSE surgery between January 2019 and May 2021. We questioned the visual analog score (VAS) for pain symptoms, the short form-36 (SF-36) for health survey questionnaire, The Female Sexual Function Index (FSFI), EHP-5 for endometriosis health profile, The Hospital Anxiety and Depression Scale (HADS), OAB-V8 for overactive bladder symptoms and Constipation Severity Instrument (CSI).

Results:

VAS, EHP-5, and SF-36 scores were better at postoperative third and sixth months than preoperative values ( p < 0.05). There were no statistically significant differences in terms of FSFI, OAB-V8, HADS, and the CSI.

Conclusions:

Laparoscopic side-to-end anastomosis with vaginal NOSE surgery is feasible, scarless, and could be offered to patients with deep symptomatic bowel endometriosis.

Endometriosis and Sexual Functioning: How Much Do Cognitive and Psycho-Emotional Factors Matter?

Women with endometriosis often suffer from genito-pelvic pain. The objective of the present study was to analyze the relationship between cognitive and psycho-emotional factors and sexual functioning of women with endometriosis, comparing women with and without endometriosis. A total of 87 women with endometriosis (EG) and 100 women without endometriosis (CG) completed a socio-demographic questionnaire; the short-form of McGill Pain Questionnaire (SF-MPQ); the Female Sexual Functioning Index (FSFI); the Sexual Distress Scale (SDS); the Symptoms Checklist (SCL-90-R); the Toronto Alexithymia Scale (TAS-20); the Positive and Negative Affects Scale (PANAS); the Sexual Dysfunctional Belief Questionnaire (SDBQ); the Sexual Modes Questionnaire (SMQ); and the Questionnaire of Cognitive Schema Activation in Sexual Context (QCSASC). EG obtained worse scores than CG in SF-MPQ, Pain subscale of FSFI, and SDS. EG reached higher scores than CG on almost all scales of SCL-90-R and lower scores in the “Identifying Feelings” scale of TAS-20. Furthermore, EG reported more negative emotions toward sexuality than CG (PANAS) higher scores on the “Affection Primacy” scale of SDBQ and the “Helpless” sexual cognitive schema of QCSASC than CG. No significant differences were found in SMQ. Sexual health professionals should address psychological, emotional, and cognitive factors since they seem involved in patients’ sexual experiences.

Sexual function and quality of life in women with endometriosis

Endometriosis may exert a profound negative influence on the lives of individuals with the disorder, adversely affecting quality of life, participation in daily and social activities, physical and sexual functioning, relationships, educational and work productivity, mental health, and well-being. Symptoms of endometriosis represent a great source of stress and cause a substantial negative impact on the psychological parameters, on the daily life and on the physical functioning of patients. The impact of endometriosis on work attendance has very significant economic consequences, as lost productivity has an associated cost, as do career changes resulting from a decline in education due to symptoms. Endometriosis is a pathology that affects all aspects of women's lives and that thus, it must be treated with a multidisciplinary vision that includes not only a medical approach but also psychological, work, and economic support. In this specific long-term vision of patient-centered endometriosis care, aspects of quality of life and sexual health play a key role and should always be evaluated with any patient as part of a multidisciplinary management.

Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study

BACKGROUND

Deep endometriosis (DE) may significantly affect women's quality of life. Limited data exists on the effect of surgery on the several domains of sexual function.

AIM

To prospectively compare various domains of sexual function before and after laparoscopic surgery for DE.

METHODS

A prospective observational cohort study in a tertiary university-affiliated referral center. Patients with suspected DE who were planned to undergo laparoscopic surgery completed the Female Sexual Function Index questionnaire before surgery. The same questionnaire was completed by the participants 6 weeks, 6 months, and 12 months after surgery. Rate of sexual dysfunction over time was compared using multilevel logistic regression. Summary scores were then compared at each time point to the corresponding score before surgery using multilevel linear regression. Multivariable analysis was performed of potential confounders.

OUTCOMES

Change in desire, arousal, orgasm, lubrication, satisfaction and pain summary scores as well as in the full-scale score between before and after surgery.

RESULTS

We followed 149 patients with surgically confirmed DE. Sexual dysfunction rate as per the full-scale score was 75.5% before surgery and remained over 60% to 12 months after. The full-scale sexual function score improved at 6 (change in score = 2.8 ± 9.5, P = .004) and 12 months (change in score = 2.1 ± 9.9, P = .03). None of the summary scores improved at 6 weeks. Desire score (P < .001), arousal score (P = .02), and pain score (P = .01) improved at 6 months. Desire score (P = .03) and pain score (P = .01) also improved at 12 months, as compared to before surgery. On multivariable multilevel analysis, scores before surgery significantly contributed to the scores after surgery (P < .001).

CLINICAL TRANSLATION

While sexual function improved after surgery, dysfunction rate remained substantial. Proper preoperative counseling should address sexual function measures and clinical and research attention should be given to seek ways to further reduce sexual dysfunction.

STRENGTHS AND LIMITATIONS

The main strengths of our study are the prospective design, the relatively long follow-up and the use of a detailed validated questionnaire allowing assessment of a large variety of clinically relevant sexual function domains and scores as well as a full-scale score. Among our limitations are the lower response rate at 12 months and the limited generalizability as this is a single center study.

CONCLUSION

Sexual function is a major and often under reported domain of quality of life. Further research is needed to identify the specific populations who may improve, not change or experience deterioration in their sexual functioning after surgery. Dior UP, Reddington C, Cheng C, et al. Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study. J Sex Med 2022;19:280-289.

The effect of dydrogesterone on sexual function in endometriosis

Endometriosis is an oestrogen-dependent chronic disease, which is commonly regarded as a disease of reproductive-aged women. We aimed to evaluate the sexual function with Female Sexual Function Index (FSFI) in women with endometriosis who received dydrogesterone for 6 months. A total of 79 women with endometriomas were recruited in the study group and received 10 mg dydrogesterone tablets orally for 6 months. FSFI and visual analog scale (VAS) scores for each patient before and after treatment were recorded. When before treatment VAS scores and after treatment VAS scores (5.7 ± 1.27, 3.97 ± 1.01, respectively) were compared, a significant decrease was observed (p = .001). A significant increase in mean orgasm scores (3.23 ± 0.6 vs. 3.57 ± 0.65, p = .01) and means satisfaction scores (3.85 ± 0.48 vs. 4.10 ± 0.38, p < .001) were observed. In addition, means desire scores were also significantly higher following treatment (p = .01). In conclusion, this study showed that FSFI scores were increased after 6 months of dydrogesterone treatment in patients with endometriosis. Desire, satisfaction, orgasm and pain scores improved significantly, and sexual dysfunction decreased after treatment.Impact statementWhat is already known on this subject? Endometriosis is a chronic inflammatory disease associated with severe dysmenorrhoea, pelvic pain, dyspareunia, painful gastrointestinal symptoms and sub-fertility are among the symptoms. These symptoms can be responsible for a significant decrease in the quality of life scores of the patients. Dydrogesterone is a synthetic progesterone derivative, which suppresses oestrogen levels and ovulation. Dydrogesterone's effect on pain relief in endometriosis patients has already been shown, but it's role on the sexual dysfunction observed in women with endometriosis has not yet been questioned.What do the results of this study add? To the best of our knowledge this is the first study showing the effects of dydrogesterone on sexual function in patients with endometriosis.What are the implications of these findings for clinical practice and/or further research? Dydrogesterone can safely be used in medical treatment of endometriosis not only for pain relief but also patients with additional complaints such as sexual dysfunction can benefit from this treatment. Future studies with larger cohorts and long-term follow-ups are needed to validate our results.

Endometriosis-associated pain: a review of quality of life, sexual health and couple relationship

INTRODUCTION

Endometriosis is a chronic gynecological disease that affects women's quality of life, sexuality, and relationship. Endometriosis-associated pain plays an essential role in well-being impairment. The present review aimed to analyze literature about endometriosis-associated pain and quality of life, sexual health, and quality of the relationship, assessing the role of the biopsychosocial factors involved and the women's pain experience.

EVIDENCE ACQUISITION

Bibliographic research of relevant articles published from 2015 to 2020 in PubMed, Google Scholar, Web of Science, Scopus, EBSCO, and Cochrane Library.

EVIDENCE SYNTHESIS

Endometriosis is associated with impairing all women's quality of life domains, and pain appears to be the most influential variable. The pain mechanism is not simple and implies several biological, psychological, and social factors. Women's sexual health is also impaired, and patients report dyspareunia, sexual dysfunctions, dissatisfaction, and distress. Partners' sexual well being is compromised as well. Endometriosis negatively influences relationship quality, and the illness burden affects both couple members.

CONCLUSIONS

A multidisciplinary team using a couple-centered and a biopsychosocial approach is crucial to provide appropriate treatment for endometriosis-associated pain. A better comprehension of all bio-psycho-social aspects implicated in women's well-being and pain experience needs more research.

The effect of endometriosis on sexual function as assessed with the Female Sexual Function Index: systematic review and meta-analysis

AIM

To systematically compare sexual function between non-treated women with and without endometriosis.

METHODS

A systematic review was performed on PubMed/Medline, Scopus, EMBASE, Web of Science and Cochrane Library databases searching studies that analyzed sexual function (assessed with the 19-item Female Sexual Function Index [FSFI]), and dyspareunia, chronic pelvic pain and dysmenorrhea (assessed with a visual analogue scale [VAS]) in women with and with endometriosis.

RESULTS

In 4 studies, non-treated women with endometriosis presented a higher risk of female sexual dysfunction (mean total FSFI score ≤ 26.55; OR = 2.38; 95% confidence interval [CI] = 1.12, 5.04). Although mean total FSFI scores were not significantly different between women with and without endometriosis (mean difference [MD] = -2.15; 95% CI -4.96, 0.67); all FSFI domain scores were significantly lower in women with endometriosis (n = 4 studies): desire (MD = -0.43; 95% CI -0.57, -0.19); arousal (MD = -0.66; 95% CI -1.15, -0.17); lubrication (MD = -0.41; 95% CI -0.79, -0.02); orgasm (MD = -0.40; 95% CI -0.73, -0.06); satisfaction (MD = -0.45; 95% CI -0.72, -0.18); and pain (MD = -1.03; 95% CI -1.34, -0.72). Women with endometriosis displayed differences (more severity) in terms of VAS scores (2 studies) for dyspareunia (MD = 1.88; 95% CI 0.38, 3.37) and chronic pelvic pain (MD = 2.92; 95% CI 1.26, 4.58); but not for dysmenorrhea.

CONCLUSION

Non-treated women with endometriosis displayed altered sexual function as evidenced by lower scores in all FSFI domains, and severity of dyspareunia and chronic pelvic pain.

Use of dienogest in endometriosis: a narrative literature review and expert commentary

Objective: Endometriosis affects up to 10% of women of reproductive age, and the main goal of treatment is to relieve symptoms. Progestins have been the mainstay of endometriosis suppression, of which dienogest has become an important option in many parts of the world. This is an expert literature review, with recommendations on the use of dienogest in the context of various clinical considerations when treating endometriosis.Methods: A search of PubMed was conducted for papers published between 2007 and 2019 on the use of dienogest in endometriosis. Experts reviewed these and included those they considered most relevant in clinical practice, according to their own clinical experience.Results: Evidence regarding the long-term use (>15 months) of dienogest for the management of endometriosis is presented, with experts concluding that the efficacy of dienogest should be assessed primarily on its impact on pain and quality of life. Fertility preservation, the option to avoid or delay surgery, and managing bleeding irregularities that can occur with this treatment are also considered. Counseling women on potential bleeding risks before starting treatment may be helpful, and evidence suggests that few women discontinue treatment for this reason, with the benefits of treatment outweighing any impact of bleeding irregularities.Conclusions: Overall, the evidence demonstrates that dienogest offers an effective and tolerable alternative or adjunct to surgery and provides many advantages over combined hormonal contraceptives for the treatment of endometriosis. It is important that treatment guidelines are followed and care is tailored to the woman's individual needs and desires.